=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336107515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRE FOOTCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 01/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 N FRONT ST
-----------------------------------------------------
City | PHILIPSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16866-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-342-4844
-----------------------------------------------------
Fax | 814-342-4866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 E FOSTER AVE
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16801-5724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-237-3338
-----------------------------------------------------
Fax | 814-237-1680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THOMAS E MOLLO
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 814-237-3338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------